Key Elements of Psychotropic Stewardship Promote Responsible, Appropriate Prescribing

It is estimated that between 21% and 45% of people with intellectual and developmental disabilities (I/DD) are taking a psychotropic. These medications are often prescribed to manage a behavioral issue, despite little evidence to support their use for this reason. Increasingly, psychotropic stewardship is being embraced to ensure appropriate use of these medications in this population as well as to promote the most effective way to manage behaviors, including prioritizing non-pharmacologic interventions.

While psychotropic stewardship needs to be customized for each organization and the individuals it serves, there are several elements that any such effort should address. These include:

• Risks associated with psychotropic use. Typical antipsychotics, or first-generation antipsychotics, can be used to treat acute psychosis and can be useful in managing chronic psychotic disorders such as schizophrenia. However, these agents can cause significant side effects such as tardive dyskinesia and extrapyramidal symptoms (EPS), which are Parkinson’s-like effects. Atypical antipsychotics, or second-generation antipsychotics, are also used in the treatment of acute psychosis and conditions such as bipolar mania and acute agitation, but have a lower risk of causing tardive dyskinesia and EPS. However, the atypical antipsychotic drugs can also cause side effects, which may include: weight gain, low blood pressure, cardiac effects, cataracts, and sexual dysfunction.

Children with I/DD can also suffer psychotropic medication side effects, and may experience problems such as somnolence, respiratory infections, hyperactivity/impulsivity, and increased appetite and weight gain. The prescriber, working with the pharmacist, should weigh the risks and benefits of these medications and determine with an alternative medication or non-drug intervention can be used.

“When it is determined that a psychotropic is appropriate, careful monitoring for side effects and complications is essential,” said William Mills, senior vice president of medical affairs for BrightSpring Health Services.

• Full assessment for behaviors. “The most inappropriate use of a psychotropic is using the drug as a crutch instead of really understanding the stimuli causing a behavioral disturbance,” said Mills. By assessing all possible reasons behind behavioral issues, it may be possible to identify a better, alternative medication or it may enable the team to avoid any drug treatment. For instance, Mills said, “It may be as simple as having a light on when someone sleeps better in the dark or a patient seeing a caregiver as disrespectful or threatening in some way.” He added, “Sometimes the prescriber doesn’t know the whole situation, and it’s easier to prescribe a psychotropic. That’s not a good idea.” There also may be physical or medical causes for behaviors such as an infection, low blood oxygen, or pain. These should all be explored.

• Family education. It is important for families to understand the risks of psychotropics and the importance of attempting non-pharmacologic approaches to managing issues such as behaviors or insomnia before resorting to medications. These conversations aren’t one-size-fits-all. Mills suggested, “Depersonalize it and talk about studies that show the impact of psychotropics, then personalize it by discussing possible triggers for behaviors or lifestyle issues or preferences that may be negatively impacting sleep or quality of life.” The person’s wishes and preferences should be considered and, with family input, weighed against the potential risks of medication therapy.
• Role of pharmacist and care team. Everyone on the care team may have insights that can help identify reasons for behaviors, insomnia, or other problems that may be resolved without medications. When a psychotropic is determined to be appropriate, team members can help monitor for adverse drug reactions and red flags such as if the person is sleeping more than usual, is unsteady on their feet, or seems lethargic or confused. The pharmacist should review any individual on a psychotropic and make recommendations for gradual dose reductions. Some psychotropics require bloodwork and other clinical monitoring, and the pharmacist needs to be involved in these as well.
• Team communication and consistency. When possible, consistent staffing will enable caregivers to really know patients and be better positioned to prevent and address behavioral issues and identify root causes. When this isn’t possible, a caregiver who is new for a patient should receive training and education to learn about patients as individuals and understand the risks and benefits of psychotropics.

At the same time, nurses should have a standard form or checklist to use when they call a physician about a behavioral issue with a patient. “It is important to avoid subjective, nonstructured communication. There is lots of value to structured tools such as the SBAR (Situation-Background-Assessment-Recommendation), which provides a framework for team communication,” said Mills. He added, “This can dramatically improve the nurses’ confidence as well as the prescriber’s ability to get what they need to make informed decisions.”

While every stewardship program will be a little different based on the care team, patients, and other factors, a combination of teamwork, communication, and best practices can help ensure that psychotropic use is managed effectively over time.